Healthcare Professionals

    Healthcare Professionals

Recommended Evidence-Based Interventions and Best Practices:

IPRO has built the foundation for our Care Transitions project on bringing healthcare providers from various settings together to evaluate existing transitional care systems and processes. Through our experience in the Upper Capital Region of NY, we emphasized building partnerships and collaboration among this diverse community to prioritize improved communication and care coordination. Our expertise has been convening cross-setting community meetings that include hospitals, home health agencies, nursing homes, dialysis centers, physician offices, community service organizations, and consumers. We promote and support the implementation of evidenced based interventions and best practices that improve care transitions for Medicare beneficiaries in the community.

• Care transition intervention coach model (Dr. Eric Coleman)
• Transitional care nurse model (Dr. Mary Naylor)
• Project RED (Re-Engineered Discharge)
• Project BOOST (Better Outcomes for Older adults through Safe Transitions)
• INTERACT II
• The IPAL Project: Improving palliative care
• Get Palliative Care.org
• Medication reconciliation across care settings
• Best Practices Intervention Package (BPIP): Transitional care coordination
• Transforming Care at the Bedside
• The Bridge Model
• The Guided Care Model
• Standardize patient information transfer at time of transition
• Use of electronic health record for patient information transfer
• Palliative care/Advance care planning consultation (MOLST)
• Palliative Care
  • http://www.capc.org/
  • http://www.getpalliativecare.org/
• Post Acute Physician follow-up appointment within 7 days of hospital discharge
• Teachback
• Telephone follow-up post hospital discharge using the Care Transition Measure (CTM) -3 or CTM-15
• Telemedicine
• Multidisciplinary plan of care at time of hospital discharge
• Standardized clinical protocols, guidelines across settings
• Personal health record
• Patient Activation Measure
• Past Success